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Wisconsin exchange overview

Wisconsin uses the federally run exchange, which means residents use HealthCare.gov to enroll in exchange plans.

Open enrollment for 2021 health plans will run from November 1, 2020 to December 15, 2020. But Wisconsin residents with qualifying events (including the loss of employer-sponsored coverage amid the COVID-19 pandemic) can still enroll or make changes to their coverage for 2020.

There were 14 insurers offering plans in the Wisconsin exchange in 2017, but three left at the end of 2017. Molina rejoined the exchange for 2019, and WPS (Arise Health Plan) rejoined for 2020, bringing the total number of participating insurers to 13.

Another average rate decrease for 2020, and WPS (Arise Health Plan) rejoined the exchange

Average premiums decreased in Wisconsin’s individual market in 2019, thanks to the state’s new reinsurance program. And the reinsurance program successfully kept a lid on premiums in its second year, with overall average premiums decreasing again for 2020, by 3.2 percent (as opposed to increasing by about 9 percent, which would have been the case without the reinsurance program).

A total of 13 insurers are offering plans in the Wisconsin exchange for 2020, up from 12 in 2019. They filed the following average rate changes for 2020:

Group Health Cooperative of South Central Wisconsin: 4.41 percent DECREASE

HealthPartners Insurance: 9.56 percent DECREASE

Medica Health Plans of Wisconsin: 12.22 percent DECREASE

MercyCare HMO Inc: 5.97 percent increase

Molina: 9.86 percent DECREASE (on top of an 18 percent decrease for 2019). Molina rejoined the Wisconsin exchange for 2019 (in seven counties), after exiting at the end of 2017.

Network Health: 7.45 percent DECREASE

Quartz Health Benefits: 1.32 percent DECREASE

Security Health Plan of Wisconsin, Inc: 4.69 percent increase

WPS (Arise Health Plan): 1.14 percent DECREASE (Arise Health Plan is rejoining the Wisconsin exchange for 2020, in rating area 11, after only selling plans outside the exchange in 2017, 2018, and 2019).

For perspective, here’s a look at how premiums have changed in Wisconsin’s exchange in previous years:

2015: Average rate increase of 3.2 percent in the state’s individual market. For a 40-year-old non-smoker, a Commonwealth Fund analysis calculated an average rate increase of 7 percent in the exchange in Wisconsin for 2015, across all metal levels.

2018: Average rate increase of 36 percent. A substantial portion of the average rate increase was due to the fact that cost-sharing reductions (CSR) are no longer being funded by the federal government (Trump clarified in mid-October 2017 that the funding would end, but Wisconsin insurers had already based their rates for 2018 on the assumption that the funding would end, so no changes were necessary after the funding was official cut off; the Wisconsin Office of the Insurance Commissioner had directed insurers in July 2017 to revise their rates to reflect the assumption that CSR funding would not continue).

2020 enrollment down about 5%, falling for the third year in a row

During the open enrollment period for 2020 coverage, 195,498 people enrolled in private individual market plans through Wisconsin’s exchange. This was down from nearly 206,000 enrollees the year before, and was the third year in a row with declining enrollment.

In most states that use HealthCare.gov, peak enrollment occurred in 2016, with declining enrollment since then. But enrollment in Wisconsin’s exchange peaked in 2017. Declining enrollment has been caused by a variety of factors: Increasing premiums for people who don’t get premium subsidies, the elimination of the individual mandate penalty after the end of 2018, the expansion of short-term plans and association health plans as alternatives to individual market coverage, and the Trump Administration’s decision to sharply reduce funding for exchange marketing and enrollment assistance.

For perspective, here’s a look at QHP enrollment in Wisconsin’s exchange during open enrollment for each year that ACA-compliant coverage has been offered:

Since 2019, Wisconsin has received federal funding for a reinsurance program that is stabilizing the individual market

In March 2018, Wisconsin enacted SB770 (Act 138). The legislation directed the state to submit a 1332 waiver to CMS, seeking federal funding for a reinsurance program in Wisconsin (Democratic efforts to include amendments in SB770 calling for a Medicaid buy-in program and a “robust rate review” process were unsuccessful).

Alaska, Oregon, and Minnesota had already established reinsurance programs, and saw much more stable premiums in their individual markets for 2018. Wisconsin is one of several states that adopted a similar program starting in 2019; as of 2020, a dozen states have reinsurance programs.

The Wisconsin Office of the Commissioner of Insurance published a draft of the 1332 waiver in March 2018, and the state submitted the final waiver proposal to CMS on April 18. The waiver proposal was approved by CMS in July 2018, providing federal funding for the state’s reinsurance program for five years, starting in 2019. The state’s portion of the reinsurance program cost would come, in part, from savings due to the fact that the health insurance provider fee was suspended for 2019. The money that the state didn’t have to spend to cover the fee for the state’s group health insurance program (for state employees) and Medicaid managed care plans would instead be diverted to help fund the reinsurance program.

Wisconsin received about $128 million in federal pass-through funding in 2019, and $142 million in 2020. Because premiums are lower than they would otherwise have been without the reinsurance program, premium subsidies (paid by the federal government) are also lower, since they don’t need to be as large in order to make coverage affordable. The idea behind the pass-through funding is that the state gets to take the money that the federal government saves due to lower premium subsidies, and use it to fund the reinsurance program.

Under Wisconsin’s reinsurance program, the state picks up 50 percent of the cost of a claim once it reaches $50,000. The state continues to pay 50 percent of the cost until the claim reaches $250,000 (these parameters vary from one state to another, among the states that have implemented reinsurance programs).

For 2019 coverage, rate filings in Wisconsin were due in early July (before the federal funding for reinsurance had been approved), so insurers in Wisconsin had to submit two sets of rates for 2019 plans — one based on the reinsurance program being approved (with lower rates that reflect the decreased risk to insurers), and one based on the status quo, without reinsurance. Ultimately, the lower rates were implemented, since the federal funding was approved.

Governor Walker’s office initially stated that average premiums for 2019 would be 3.5 percent lower in 2019 than they were in 2018, due to the implementation of the reinsurance program. In October, they revised that to an average rate decrease of 4.2 percent.

Insurer participation in Wisconsin’s exchange: Changes over time

2014 and 2015
The Wisconsin exchange had 13 carriers in 2014, but had 15 for 2015, with the entry of two new carriers:UnitedHealthcare and Managed Health Services Insurance Corporation (AmBetter).

2016
In October 2015, less than a week before open enrollment began for 2016 coverage, Anthem Blue Cross Blue Shield announced that they would pull out of the Wisconsin exchange in three counties: Milwaukee, Racine and Kenosha, where nearly a quarter of the state’s population resides. Anthem also announced that they would significantly reduce the number of available plans in 34 other counties in the state.

Network Health joined the Wisconsin exchange for 2016, offering plans in seven counties: Calumet, Milwaukee, Outagamie, Ozaukee, Racine, Waukesha, and Winnebago. The plans were also available outside the exchange.

2017
14 carriers offered plans in the Wisconsin exchange for 2017. Ambetter, United, Physicians Plus, and WPS (Arise Health Plan) exited the exchange at the end of 2016, but Children’s Community Health Plan and Aspirus Arise joined the exchange for 2017:

Ambetter (Managed Health Services Insurance Corp.) also left the individual market in Wisconsin at the end of 2016.

WPS (Arise) announced that they would not offer plans in the exchange in 2017, but would continue to offer plans outside the exchange. According to their rate filing, They only offered off-exchange plans in 19.5 counties (out of the 39 counties where they offered coverage in 2016), and limited their off-exchange plans to Bronze and Catastrophic plans in 2017. Arise had a “small share” of the individual market in 2016. But Aspirus Arise (a new, separate entity) began offering coverage in north-central Wisconsin in 2017, on and off the exchange.

In their rate filing memo, Physicians Plus confirmed that their plans would only be offered outside the exchange in Wisconsin in 2017, and that they would exit the exchange at the end of 2016.

Humana left the individual market in Wisconsin at the end of 2016, as was the case in at least a handful of other states. Humana did not participate in the exchange in Wisconsin, so their exit only impacted off-exchange plans. According to Humana’s letter regarding their exit, there were 6,639 members whose coverage was scheduled to terminate at the end of 2016.

2018In 2018, Wisconsin still had one of the most robust exchanges in the country in terms of the number of participating insurers, but Anthem, Molina, and Health Tradition Health Plans all left the exchange at the end of 2017, resulting in about 75,000 people needing to select new plans for 2018.

Anthem only offered one off-exchange plan in one county in 2018 (Menominee County, which has a population of just 4,500 and is one of the poorest counties in the state; off-exchange plans are not eligible for premium subsidies, so participation in this plan has likely been extremely low). The continuation of off-exchange coverage in Menominee County prevented a full market exit, which means that Anthem has the option to return to the state’s full individual market — including the exchange if they wish to do so — at any point in the future. A full market exit would trigger a five-year lockout from the state’s individual market, per federal regulations that pre-date the ACA.

Molina announced in August 2017 that they would exit the exchange in Wisconsin (and in Utah) at the end of 2017. Their total enrollment in Wisconsin, which included people with Medicaid and Medicare, was 130,000, and the Milwaukee Journal Sentinel reported that about 55,000 of those people had coverage in the individual market (it’s unclear what percentage of that population had on-exchange coverage, but it’s likely the majority; Molina did not market their ACA-compliant plans off-exchange for 2017, although some of their individual market enrollees likely had grandmothered and grandfathered plans).

Molina explained that Utah and Wisconsin were among the states where their marketplace performance had been “most disappointing” and that during the second quarter of 2017, Molina had spent 128 percent of the premiums collected in the Utah and Wisconsin exchanges on medical care (for reference, the ACA requires insurers to spend at least 80 percent of premiums on medical care as opposed to administrative expenses, but an amount of 100 percent or more is clearly unsustainable, as it means that the insurer is spending more on claims than it’s collecting in premiums, with no room for administrative costs at all).

Although Gunderson plans did not appear in the rate filings for 2018, Unity Health Plans filings were submitted. Unity already offered plans in the exchange in 2017, and their website noted that they were affiliated with UW Health/UnityPoint as the on-exchange insurance entity. But the Gunderson/Unity group transitioned to marketing plans under the name Quartz, and Unity’s website now redirects to the Quartz site. Quartz plans will be available in the Wisconsin exchange for 2020, but not Gunderson or Unity plans.

As rate filings trickled in around the country in the spring and early summer of 2017, there were initially 82 counties nationwide that didn’t have any exchange plans filed for 2018. One of them was Menominee County, Wisconsin, where 47 people were enrolled in exchange plans in 2017, and where Molina had been the only insurer offering exchange plans in 2017. Security Health Plan eventually stepped in to provide coverage in the exchange in Menominee County in 2018.

2019
Molina continued to offer one bronze plan off-exchange, in Shawano County in 2018. But the premium on that plan increased by 106.3 percent that year, and it was not actively marketed. But by continuing to offer the off-exchange plans, Molina avoided a full market exit and was able to rejoin the exchange for 2019. They offered silver and gold plans in seven counties in the exchange in 2019, and discontinued the off-exchange bronze plan that they had offered in 2018 in Shawano County (it really only served as a place-holder so the Molina would have the option to return to the exchange/individual market in 2019 or a future year).

2020
WSP (Arise Health Plan) is returning to the Wisconsin exchange for 2020, with plans available in rating area 11. This brings the total number of participating insurers to 13.

Medicaid buy-in failed to pass

In the summer of 2017, Democratic state lawmakers in Wisconsin introduced legislation in the Assembly (AB449) and Senate (SB363) that would have allowed Wisconsin residents to buy into BadgerCare, the state’s Medicaid program (Medicaid in Wisconsin has not been expanded under the ACA, but it does cover people with income under the poverty level, so there is no coverage gap in Wisconsin). The idea was that BadgerCare would serve as a public option, competing with private insurance plans in the individual market.

The day after House Republicans passed the American Health Care Act (AHCA), Ted Nickel, who was at that time Wisconsin’s Insurance Commissioner, voiced his support for the legislation. In a May 2017 MacIver Institute article, Nickel welcomed the potential return to high-risk pools under the AHCA, and waxed about the benefits of Wisconsin’s pre-ACA high-risk pool, the Health Insurance Risk-Sharing Plan (HIRSP), which closed once health plans in the private market became guaranteed-issue regardless of medical history.

Nickel stated that for three decades, HIRSP provided solid coverage to Wisconsin residents, and indicated that at least some of those residents are worse off under the ACA (it’s noteworthy that people who qualify for significant premium subsidies in the exchange are likely paying lower premiums now than they were under HIRSP, but not everyone qualifies for substantial subsidies).

Governor Walker initially indicated that Wisconsin would be open to pursuing an AHCA waiver to eliminate some of the ACA’s consumer protections, which would have created an opportunity to reinstate HIRSP (the AHCA would have allowed states to opt-out of the ACA’s essential health benefits requirements; they would also have been allowed to let insurers charge premiums based on applicants’ medical history if the applicant had a gap in coverage during the prior year). But by the next day, after significant backlash over the potential evisceration of protections for people with pre-existing conditions, Walker appeared to backtrack on his position, saying that the state was “not looking to change” the current pre-existing condition protections.

All of that is a moot point, since the AHCA was never enacted. But it did highlight the health care reform positions of Wisconsin’s governor and insurance commissioner under the Walker administration. Governor Evers appointed Mark Afable as the state’s new Insurance Commissioner in January 2019.

Governor Walker and Insurance Commissioner Nickel (who was elected president of the National Association of Insurance Commissioners in December 2016) argued that the government does not have the right to force people into contracts with insurance carriers, or to direct people to one carrier over another. They also noted that as far as they were concerned, the proposal to automatically re-enroll people in plans from different carriers essentially amounted to selling health insurance without a license, which is not permitted in Wisconsin (or any other state, for that matter).

The Wisconsin Office of the Insurance Commissioner issued a press release in which they informed consumers how to opt-out of HealthCare.gov’s auto re-enrollment. Consumers could, of course, simply select a new plan by December 15 in order to avoid auto re-enrollment. But if they did not wish to continue to have coverage through the exchange, they could also log back into the exchange by December 15 and follow the steps to opt-out of auto re-enrollment (this is available to all HealthCare.gov enrollees in every state; it’s not specific to Wisconsin, but Wisconsin officials have been vocal in letting their residents know about the opt-out feature)

On October 31, 2016, the day before open enrollment began, Nickel published a bulletin for insurers in Wisconsin, reiterating the fact that the state considers HealthCare.gov’s automatic re-enrollment to be in violation of Wisconsin insurance law, but noting that the automatic re-enrollment would happen anyway, for up to 37,000 Wisconsin residents (many of them likely returned to the exchange to pick their own plans or opt-out of auto re-enrollment prior to mid-December, and were thus not automatically re-enrolled in plans selected by the exchange).

The October 31 bulletin laid out some guidelines for insurers to follow in the event that they received enrollments from HealthCare.gov that had not been initiated by the consumer (ie, that were automatic re-enrollments). Insurers that followed the guidelines did whatever they could to inform the consumers of the plan selection and gain consumer consent to enroll in the plan. By doing so, the carriers remained in compliance with Wisconsin insurance guidelines.

CO-OP still operational; one of just four left in the nation

Wisconsin is one of the states that has an ACA-created CO-OP. Common Ground Healthcare Cooperative received federal loans to get up and running, and has been offering health insurance in Wisconsin since the beginning of 2014. Initially, there were 23 CO-OPs offering plans in 25 states. But only four are still operational as of 2020; Common Ground is one of them.

Common Ground Healthcare Cooperative lost money in 2014 — as did all but one of the CO-OPs. Their claims exceeded premiums by almost $44 million, and they enrolled more than two and a half times as many people as they had expected in 2014. All carriers that ended up with higher-than-expected claims were supposed to get risk corridor payments to help cushion the losses, but HHS announced in October 2015 that payments would be just 12.6 percent of the amount due. This threw several CO-OPs into financial crises, and Insurance Commissioners across the country had to make some tough decisions regarding the financial viability of the CO-OPs.

But Common Ground survived. In November 2015, Common Ground announced that they were adding Bellin Health System to their Envision Integrated Care Network, which also includes Aurora Health Care. Of the 11 CO-OPs that were still operational at the start of 2016, seven had closed by the end of 2017. Common Ground is among the four that remained operational, and that continues to be the case in 2020. Although they lost nearly $17 million in the first half of 2016, they secured a capital infusion from an undisclosed source in September 2016 that allowed them to remain financially viable heading into 2017.

Common Ground’s average premiums increased by 63 percent in 2018. But for 2019, Common Ground decreased their average premiums by nearly 19 percent, indicating a new level of stability for the insurer. For 2020, Common Ground again decreased premiums, this time by more than 9 percent. The CO-OP had about 29,000 members in 2017.

Bill to increase rate oversight did not pass

In September 2015, Wisconsin State Senator Chris Larson and State Rep. Debra Kolste announced the introduction of new legislation (AB359) that would have required Wisconsin to utilize a robust rate review process, much the same as many other states. Among other things, the legislation would have required the Insurance Commissioner to hold public hearings on proposed rate increases over ten percent, and would also have given the Insurance Commissioner the ability to deny rate hikes that aren’t justified by claims costs.

The legislation noted that “current law prohibits premium rates from being excessive, inadequate, or unfairly discriminatory”, and the state does have an outside actuary that reviews the rates. HHS also reviews proposed rates that include a premium increase of 15 percent or more (this threshold used to be 10 percent). But Larson and Kolste’s bill would have given the Wisconsin Insurance Commissioner far more regulatory oversight for health insurance premiums. However, it was considered unlikely that the bill would pass in the state’s Republican-dominated legislature; indeed, by mid-April 2016, the legislation was dead.

Wisconsin Medicaid – a unique approach…

Wisconsin has not expanded Medicaid under the ACA, but has taken a more proactive approach than most non-expansion states in providing coverage for people living in poverty. Wisconsin dropped the existing BadgerCare Medicaid eligibility to 100% of poverty level, which resulted in 72,000 people losing BadgerCare eligibility. Since subsidies for private Obamacare plans purchased in the exchange begin at 100% of poverty level, the residents who lost BadgerCare eligibility were able to purchase heavily subsidized plans in the exchange instead.

However, critics noted that a lot of those 72,000 people (with incomes just over 100% of poverty) were probably unable to afford a private plan, even with the available cost-sharing and premium subsidies.

As of the beginning of September 2014, the state estimated that 25,800 former BadgerCare members had not yet enrolled in a subsidized plan through the exchange. They initially had until June 30 to do so, but HHS granted them another special enrollment period during which they could apply for a subsidized plan in the federally-facilitated Wisconsin exchange. The Wisconsin Department of Health Services sent letters to the former BadgerCare enrollees who had not yet obtained new coverage, informing them of the special enrollment period.

But an additional 83,000 childless adults with incomes below 100% of poverty level were newly eligible for BadgerCare in 2014. Wisconsin created its own version of Medicaid reform without using the federal funds allocated by the ACA. As a result, the state was able to make its own rules, and people in Wisconsin with household incomes between 100% and 138% of the poverty level are expected to purchase subsidized private plans — they are not eligible for Medicaid.

…but not fully expanded Medicaid

Technically, this means Wisconsin has not expanded Medicaid under the ACA (if it did, people with incomes up to 138 percent of poverty would be eligible for Medicaid and the state would receive federal funding for Medicaid expansion). Although then-Governor Scott Walker received criticism from consumer advocates, among states that have not expanded Medicaid, Wisconsin is the only one without a coverage gap, since BadgerCare was expanded to cover everyone up to 100% of poverty level (in most states that did not expand Medicaid, eligibility limits are far lower than that).

Nevertheless, 19 Wisconsin counties and the city of Kenosha added referendum questions to their ballots in November 2014, asking citizens to weigh in on Gov. Walker’s decision to not fully expand Medicaid under the ACA. Voters passed all 20 of the ballot initiatives, but they are essentially just a way of communicating resident wishes to lawmakers, as the final decision on expanding Medicaid is up to the Governor and the state’s lawmakers.

Over four years, it’s was estimated that the total cost to state and federal taxpayers for Wisconsin’s unique approach to Medicaid would be $2 billion more than it would have been under straight Medicaid expansion as called for in the ACA. That’s because subsidizing enrollees in the exchange (in this case, people with income between 101 and 138 percent of the poverty level) cost the federal government more than Medicaid would, and because state taxpayers are having to shoulder much more of the burden of paying for Medicaid for those under the poverty level than they would if the state expanded Medicaid (in that case, the federal government would pay 90 percent of the cost).

Wisconsin exchange history

Former Gov. Walker had previously expressed a preference for a state-run exchange rather than a “one size fits all” federally operated exchange. In 2011, Walker used an executive order to create the Office of Free Market Health Care to plan for a Wisconsin exchange. Walker’s plan for a “free-market, consumer-driven approach” leaned heavily on an insurance marketplace implemented by former Gov. Jim Doyle. According to one state insurance expert, the only notable change proposed by Walker was to put the exchange online.

However, Walker showed a changed mindset in 2012, returning a $38 million federal grant and closing the Office of Free Market Health Care. In announcing his November 2012 decision to accept a federally operated exchange, Walker said the state would have no real control and much higher financial risk with a state-run exchange.

Wisconsin was one of only seven states with a federally facilitated marketplace that had at least ten carriers in 2014. But despite the robust competition, Wisconsin’s exchange rates were relatively high in 2014. The average premium for the lowest-cost bronze plan in Wisconsin in 2014 was $287, compared with $249 nationally.

Citizen Action of Wisconsin, a liberal-leaning group pushing for Medicaid expansion and a public option in the state, highlighted the very different ACA paths taken by Minnesota and Wisconsin, and placed some of the blame for Wisconsin’s high rates on the fact that the state ultimately took a hands-off approach to the exchange and also refused to accept federal funds to expand Medicaid.